If you're looking for a comprehensive Medicare Advantage PPO plan with prescription drug benefits, we are pleased to offer Moda Health
PPORX. This plan was designed with both your medical and prescription drug needs in mind, offering excellent
benefits that fit your lifestyle. With the Moda Health PPORX plan, you'll enjoy the following benefits:

A statewide network of more than 5,500 providers, plus the freedom to use out-of-network Medicare providers

Low deductible of $100

Worldwide coverage for emergency services

Protection of an annual out-of-pocket maximum

Routine eye exam once every two years

No referrals required

12-month travel benefit within the United States

Silver&Fit® Fitness Program

Coordination of care services

Part D prescription drug coverage

Medical coverage

Moda Health PPORX (PPO)

In-network

Out-of-network

Monthly health plan premium

$119.00

Annual out-of-pocket maximum

$3,400

Annual medical deductible

$100

Primary care provider

$25 copay

$40 copay

Specialist office visit

$35 copay

$50 copay

Inpatient hospital care (per stay) (1) (3)

$295 per day
for days 1-5

$400 per day for days 1-5

Outpatient surgery (per stay) (3)

$295 hospital
or ASC (2)

30% of the cost for hospital
or ASC (2)

Medicare-covered preventive services

$0 copay

Lab services

$0 copay

X-ray, CT, MRI, PET, etc. (3)

20% coinsurance

30% coinsurance

Routine vision exam every two years

$35 copay

Travel benefit in the U.S.

12 months

Silver&Fit® Fitness Program

You must use a facility participating in the ASH Fitness network. $0 copay

Moda Health Extra Care is available at an additional $12 premium per month and includes non-Medicare covered services such as
chiropractic, naturopathic, acupuncture, hearing services, and vision hardware. 50% coinsurance for services up to a combined $500 maximum benefit per year.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or
copayments/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium.

Out-of-network/non-contracted providers are under no obligation to treat Moda Health Plan, Inc. members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our Member Services number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at 1-877-299-9062. This is a free service. To see this message in another language refer to Multi-language Interpreter Services notice.

Last updated October 1, 2017
Y0115_WEB_2018A Approved

We're sorry, we don't currently offer Medicare plans in . View our plans in or use the dropdown at the top of the page to view Medicare plans in Oregon.

If you're looking for a comprehensive Medicare Advantage PPO plan with prescription drug benefits, we are pleased to offer Moda Health
PPORX. This plan was designed with both your medical and prescription drug needs in mind, offering excellent
benefits that fit your lifestyle. With the Moda Health PPORX plan, you'll enjoy the following benefits:

A statewide network of more than 9,500 providers, plus the freedom to use out-of-network Medicare providers

Low deductible of $125

Worldwide coverage for emergency services

Protection of an annual out-of-pocket maximum

Routine eye exam once every two years

No referrals required

12-month travel benefit within the United States

Silver&Fit® Fitness Program

Coordination of care services

Part D prescription drug coverage

Medical coverage

Moda Health PPORX (PPO)

In-network

Out-of-network

Monthly health plan premium

$98.00

Annual out-of-pocket maximum

$3,400

Annual medical deductible

$125

Primary care provider

$25 copay

$40 copay

Specialist office visit

$35 copay

$50 copay

Inpatient hospital care (per stay) (1) (3)

$295 per day
for days 1-5

$400 per day for days 1-5

Outpatient surgery (per stay) (3)

$295 hospital
or ASC (2)

30% of the cost for hospital
or ASC (2)

Medicare-covered preventive services

$0 copay

Lab services

$0 copay

X-ray, CT, MRI, PET, etc. (3)

20% coinsurance

30% coinsurance

Routine vision exam every two years

$35 copay

Travel benefit in the U.S.

12 months

Silver&Fit® Fitness Program

$0 copay

Moda Health Extra Care is available at an additional $12 premium per month and includes non-Medicare covered services such as
chiropractic, naturopathic, acupuncture, hearing services, and vision hardware. 50% coinsurance for services up to $500 maximum benefit per year.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or
copayments/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium.

Out-of-network/non-contracted providers are under no obligation to treat Moda Health Plan, Inc. members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our Member Services number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at 1-877-299-9062. This is a free service. To see this message in another language refer to Multi-language Interpreter Services notice

Last updated October 1, 2016
Y0115_WEB_2017A Approved

We're sorry, we don't currently offer Medicare plans in . View our plans in or use the dropdown at the top of the page to view Medicare plans in Oregon.

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